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This form is intended for teachers to report any incident of Code of Conduct. All Belleville School District staff members are required to enter their name and fill out ALL boxes.

PLEASE NOTE: This form is being submitted to an electronic queue for investigation. There is no guarantee that it will be read immediately.

Date of Incident:

Time of Incident:
Indicate how you learned that a student may have been a victim of harassment, intimidation or bullying:
Student's Information
First Name:
Last Name:

Student ID:


Guardian First Name:
Guardian Last Name:

Guardian Relationship:
Guardian Phone Number:

Guardian Email Address:
Teacher Contact Info

First Name:
Last Name:
Phone Number:
Best time to call:

Infractions (choose all that apply)?

Where did the incident happen (choose all that apply)?

Document Upload
Optional: Please attach any images, videos, or other files relevant to this incident. If you wish to select multiple files for upload, click "Choose Files" and then hold the Ctrl button on your keyboard while choosing each file.
Do not upload any images or videos of a sexual nature.

Description of Incident
Is there any additional relevant information that you would like to provide?
Be sure to enter all known information before submitting.